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When Pot Goes From Illegal To Recreational, Schools Face A Dilemma

NPR Health Blog - Sun, 02/22/2015 - 4:27pm
When Pot Goes From Illegal To Recreational, Schools Face A Dilemma February 22, 2015 4:27 PM ET


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Schools in Colorado are trying to find effective ways to teach the health effects of marijuana use. "When it's legal for your parents to smoke it or grow it," says one educator, "that changes the conversation."

David Zalubowski/AP

Like many schools across Colorado, Arapahoe Ridge High School in Boulder has seen an increase in overall drug incidents since recreational marijuana became legal.

While public schools aren't required to report marijuana incidents separately from other drugs such as cocaine, evidence compiled by Rocky Mountain PBS I-News suggests more students are using marijuana.

"Especially since we use the phrase 'recreational marijuana,' " says Odette Edbrooke, health education coordinator for the Boulder Valley School District. "Recreational implies it's fun, and it's something you do in your spare time."

And as with other Colorado schools, Arapahoe Ridge is grappling with how best to discuss the health consequences of pot use. Edbrooke says the state's changing attitudes about marijuana send students a mixed message.

"When it's legal for your parents to smoke it or grow it, that changes the conversation," Edbrooke says.

This year the Boulder Valley School District is bringing in a neuroscientist to talk to health classes about the impacts of marijuana on brain development.

The Two-Way Two Of Colorado's Neighbors Sue State Over Marijuana Law Shots - Health News Colorado Tries Hard To Convince Teens That Pot Is Bad For You Shots - Health News Evidence On Marijuana's Health Effects Is Hazy At Best

The Colorado Department of Education has not changed its statewide health curriculum guidelines since voters legalized marijuana. Up to this point, it has used money from marijuana taxes to put out a series of public service announcements on pot's negative effects.

Albert Amaya, 16, says no education campaign, either in school or on TV, could change his opinion. Amaya is a sophomore at Miami Yoder high school, east of Colorado Springs.

"I feel like, in comparison with things like alcohol and cigarettes, marijuana has far fewer long-term side effects," he says. "I saw one of the smoking commercials, and this guy couldn't start a barbecue because he was high. That's taking it to the extreme, I think. I don't think that just because you're high, that you can't function."

Senior Mercedes Wisenbaugh says what she learns in school isn't as effective as what she experiences in her own life.

"I've seen my family members, I see how lazy they get, I see how unmotivated they get," Wisenbaugh says. "I see how they're not tuned in to reality. They're in a different fog than everybody that does not smoke marijuana."

The Colorado Department of Public Health is developing a science-based marijuana education program that takes a more holistic approach, says Mike Van Dyke, section chief for environmental epidemiology and toxicology.

"Marijuana is unique, because ... this is a substance where you have a large community of people that really claim that it has a lot of health benefits," says Van Dyke. "You don't see that with tobacco."

"The messaging that probably I give my son, and that I would like the school to pick up on: I would like them to be given better coping skills," says Carol Gibbs, mother of four.

Gibbs says she's most concerned about the loss of drive among pot users. She wants her 16-year-old son to learn the best ways to deal with the stress of adolescence.

Colorado recently awarded grants, using marijuana tax revenue, to help school districts hire nurses, psychologists, counselors and social workers — addressing some of the concerns of parents like Gibbs.

"When things get tough, I want these kids to have more options than relaxing with a joint, or getting lost in their electronic devices," Gibbs says.

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Hammered And Heedless: Do Dangerous Drinking Videos Harm Teens?

NPR Health Blog - Sat, 02/21/2015 - 7:03am
Hammered And Heedless: Do Dangerous Drinking Videos Harm Teens? February 21, 2015 7:03 AM ET

If your idea of fun is being falling-down drunk, there's plenty for you on YouTube.


Type "drunk," "hammered," or "trashed" into YouTube's search bar and some pretty unsavory videos are likely to turn up.

And that can't be good for teenagers and young adults, researchers say. User-generated YouTube videos portraying dangerous drinking get hundreds of millions of views online, according a study published Friday in the journal Alcoholism: Clinical and Experimental Research.

These videos often present wild bingeing in a humorous light, the study found, without showing any of the negative consequences, like potentially fatal alcohol poisoning and accidents caused by drunk driving.

The researchers didn't reveal which videos they looked at, to avoid singling out particular YouTube users.

Our own unscientific search turned up many videos under the words "drunk fails," with people who are publicly intoxicated or completely passed out, as well as sleazier stuff like Best Drunk Girls Compilation, Part 1.

There's been lots of research on paid-for alcohol advertisements and product placement on TV shows, in the movies and in music, says Dr. Brian Primack, an associate professor of medicine and pediatrics at the University of Pittsburgh and the study's lead author. "But we haven't really looked at YouTube before," he tells Shots.

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Primack and his colleagues looked at a cross-section of 70 YouTube videos that showed unsafe drinking. Together those videos pulled in over 330 million views. Even though the videos weren't paid for by alcohol companies, nearly half of them referenced specific brands of alcohol.

The researchers weren't able analyze who is watching these videos, Primack says, because YouTube no longer makes that information publicly available. But Primack suspects that many viewers are underage, because of previous research he has done on YouTube demographics..

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It's also not clear how watching these videos may influence young people's decisions on alcohol use.

This is just a preliminary study, Primack says, but the findings highlight the fact that the Internet is full of unhealthy messages about alcohol. Researchers should look more carefully at sites like YouTube and Tumblr, as well as apps like Instagram and Snapchat, he says.

"We already know that visuals are influential for teens and peer influence is important," Primack says. "Sites like YouTube combine both. You've got video paired with likes, comments and peer-to-peer dialogue."

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We contacted YouTube, but a spokesperson declined to speak on the record. YouTube does have a policy against harmful or dangerous content and viewers can report inappropriate videos for review.

But these videos are still easy to find, Primack says, and there's no way to completely shield children from negative depictions of alcohol use, Still, he adds, "I don't think the right response is to freak out and block kids' Internet use."

Instead, parents and educators should push kids to think critically about the messages they're exposed to on the Internet, says Dr. Michael Siegel, a professor of community health at Boston University who wasn't involved in the study.

"By actually understanding and talking about it, kids become resistant to these messages," Siegel says. "They'll be able to see that these portrayals online aren't realistic."

Public health agencies could also make better use of platforms like YouTube to put out their own messages, Siegel says.

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Dissolving Contact Lenses Could Make Eye Drops Disappear

NPR Health Blog - Fri, 02/20/2015 - 1:39pm
Dissolving Contact Lenses Could Make Eye Drops Disappear February 20, 2015 1:39 PM ET Alison Bruzek

If you've ever had an eye infection, you know how annoying it can be to get drops of medicine on the eyeball a few times a day. It's an even harder task with children or for older adults who don't always have the dexterity to squeeze they used to.

That's why researchers have developed an ultra-thin contact that can be placed on the eye to deliver drugs slowly — in a matter of hours or they hope even days — before dissolving away.

Called nanowafers, these lenses are one-twentieth the thickness of a contact lens. Each wafer, made of a thin resin called polyvinyl alcohol, contains tiny reservoirs that can be filled with drugs that are released gradually.

An experimental circular disc with tiny reservoirs releases medication slowly. Then the disc dissolves.

Baylor College of Medicine

The wafer is not only less tedious than eye drops, it's more efficient, says Dr. Steven Pflugfelder, a professor of ophthalmology at Baylor College of Medicine in Dallas and an author of a study, published in the journal ACS Nano. Eye drops aren't the best way to deliver drugs to the eye, given human reflexes that cause us to blink and tear, washing the medicine away.

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The nanowafer is especially good for children, babies and elderly adults, says Pflugfelder. "As opposed to a caregiver having to instill drops multiple times a day, the caregiver could put a wafer in the eye once a day or every other day." Then the wafer's polyvinyl alcohol, the same stuff found in artificial tears, would simply dissolve away.

Unlike contacts, the wafers don't need to be placed on the cornea, but could sit on the sclera, the white part of the eye, to treat conditions like dry eye, he says.

In principle the wafer shouldn't affect vision, says Ghanashyam Acharya, an assistant professor at Baylor and another author of the paper. "The nanowafer is very thin and transparent ... and it quickly adheres to the cornea," he says. However, he adds, further studies must be done to ensure that's true for all conditions.

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The Baylor team isn't the first to try adding medication to contacts – it's been the subject of research for several decades. Other solutions have coated the lens with a film or added diamond nanogel to help bind certain drugs. But the nanowafer, Pflugfelder says, is notable for its thinness.

There is controversy over whether nanodrugs are safe. Their small size, which makes them useful, could also make them toxic. However, the nanowafers don't use free-floating nanoparticles and only use drugs already prescribed in clinics.

To test the nanowafers, Pflugfelder and his team created tiny versions for mice with eye injuries. The injuries mimicked those found in humans: "Soldiers in the army get eye injuries ... given the nature of explosive devices used," Pflugfelder tells Shots, and similar injuries can be found in the chemical industry from acid.

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The scientists loaded the tiny wells in the wafers with doxycycline, an antibiotic. The wafers were applied to the mice's eyes and the release of the antibiotic in the eye was measured through the mice's tears.

The researchers found that the wafer released the antibiotic over four hours. Furthermore, mice treated with the wafer showed signs of the drug in their eyes up to 24 hours later, but mice treated with eye drops showed none even minutes after the drops were given.

The team also tested the prescription drug Axitinib for treating corneal burns. They found that the wafer, though it contained half the dose of the eye drops (5 micrograms instead of 10 micrograms), was twice as effective at healing the eye.

"What I liked about this [study] is you have this ... wafer that has these little wells inside so beyond being able to release a drug ... one could think about delivering multiple drugs with this device," says Dean Ho, a bioengineer at UCLA who wasn't involved in the study. "It's a nice first look at a noninvasive way to deliver drugs in discrete units." Using drugs at the nanoscale is great for localizing treatment, he says, and the nanowafer is a perfect example.

The first clinical use for the nanowafer that Pflugfelder and the team are looking at is for cystinosis, a genetic condition that causes crystals of cystine, an amino acid, to build up in the cornea.

The traditional treatment, a drug called cysteamine, is delivered once an hour by eye drop to dissolve the crystals. But Pflugfelder and colleagues hope inserting the wafer once a day can accomplish the same thing. They hope to start clinical trials in a year, but don't yet know when, if all goes well, they'll be ready for market.

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Administration Grants Tax Time Reprieve For Obamacare Procrastinators

NPR Health Blog - Fri, 02/20/2015 - 11:39am
Administration Grants Tax Time Reprieve For Obamacare Procrastinators February 20, 201511:39 AM ET

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The Obama administration said Friday it will allow a special enrollment period from March 15 to April 30 for consumers who realize while filling out their taxes that they owe a fee for not signing up for coverage last year.

The special enrollment period applies to people in the 37 states covered by the federal marketplace, though some state-run exchanges are also expected to follow suit.

People will have to attest that they first became aware of the tax penalty for lack of coverage when they filled out their taxes. They will still have to pay the fine, which for last year was $95 or 1 percent of their income, whichever was greater. By signing up during the special enrollment period for 2015 they can avoid paying most of the tax penalty for this year.

The Affordable Care Act requires most Americans to have health insurance or pay a financial penalty. But some people may not realize they face a penalty for not having coverage until they file their tax returns ahead of the April 15 tax deadline.

The administration also said Friday it sent out the wrong information to 800,000 people to help them calculate whether they received too much of a subsidy for health coverage last year or too little. Those affected are being told today by email or telephone, and are being asked to wait to file their taxes until after new 1095-A forms are sent in early March.

For the 5 percent of those affected who have already filed returns for 2014, more instructions are to come from the Treasury Department, officials said. The 800,000 represents about 20 percent of the total number of people who were sent 1095-A tax forms. Officials declined to say how the mistake occurred.

The administration would not estimate how many people it expects to take advantage of the new enrollment period. Millions of Americans who did not enroll in a plan are exempt from the requirement to buy coverage because their income is too little or they qualify for other exemptions. Officials said this special enrollment would be just for this year to account for people who did not hear or heed messages about the individual insurance mandate that was included in the health law approved by Congress in 2010.

So far, 11.4 million Americans have enrolled in private health insurance through Obamacare during the open enrollment period that ended on Sunday.

Separately, administration officials have said they will allow people who had trouble completing their enrollment by Feb. 15 to finish by Sunday Feb. 22. Officials estimated it would help fewer than 150,000 people.

Kaiser Health News' Julie Appleby contributed to this story.

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UCLA Outbreak Highlights Challenge Of Curbing Infections

NPR Health Blog - Fri, 02/20/2015 - 10:09am
UCLA Outbreak Highlights Challenge Of Curbing Infections February 20, 201510:09 AM ET

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The bacterial outbreak at UCLA's Ronald Reagan Medical Center highlights shortcomings in the federal government's efforts to avert the most lethal hospital infections, which are becoming increasingly impervious to treatment.

Government efforts are hobbled, infection control experts say, by gaps in monitoring the prevalence of these resilient germs both within hospitals and beyond. The continued overuse of antibiotics — due to overprescription by doctors, patients' insistence and the widespread use in animals and crops — has helped these bacteria evolve into more dangerous forms and flourish.

In the UCLA outbreak, two patients have died and more than 100 may have been exposed to antibiotic-resistant bacteria commonly found in the digestive tract. When this germ reaches the bloodstream, fatality rates are 40 percent. The government estimates about 9,000 infections leading to 600 deaths are caused each year by carbapenem-resistant Enterobacteriaceae, or CRE.

UCLA Health says the infections probably were passed around by inadequately sterilized scopes used to peer inside a body.

Previous CRE outbreaks have occurred elsewhere in the country, including hospitals in Illinois and Seattle.

The immediate public health response has focused on the safety of the scopes and tracking down people who may have been exposed. The Food and Drug Administration Thursday issued an alert about the devices involved.

But the California outbreak comes amid the government's broader struggle to spot and battle the swelling ranks of bacteria that are impervious to most, if not all, antibiotics.

CRE is one of three kinds of infectious agents that the Centers for Disease Control and Prevention categorized as the drug-resistant threats that require the most urgent monitoring and prevention. CRE bacteria are resistant to almost all antibiotics, including carbapenems, which doctors often deploy as a last resort. The remaining treatments are often toxic.

A CDC report found that in the first six months of 2012, nearly 5 percent of hospitals reported at least one CRE infection.

Unlike the way it handles another urgent threat, Clostridium difficile, known as C. diff., the federal government does not publicly report CRE infection rates at each hospital.

The federal government also doesn't monitor the prevalence of any of these antibiotic-resistant bacteria beyond health care facilities, although California, Georgia, Minnesota and seven other states do.

"That is an example of a world-class infections system, but it's only in 10 states," said Dr. Trish Perl, an epidemiologist at the Johns Hopkins Health System in Baltimore.

"We have very targeted sources of information as opposed to an integrated and holistic system," she said. "It's like air control towers if you only had data from Chicago and Atlanta."

People can often carry CRE in their gut without injury, but it can spread outside the gut quickly in people who are taking antibiotics for other ailments or in a weakened state. Lisa McGiffert, director of the Safe Patient Project at Consumers Union, said that the CDC recommends hospitals screen all new patients for CRE. "I find it highly unlikely that many hospitals are doing that," she said. She noted that UCLA this week notified patients who underwent procedures as long ago as October that they may have been infected.

The federal government has been trying for years to get doctors and hospitals to curtail their use of antibiotics, since their proliferation has helped create these new resistant bacteria strains. The CDC has encouraged hospitals to create antibiotic stewardship programs, where experts systemically try to ensure that the bacteria-fighting drugs are the best resource and that there is evidence that they actually work on the specific infection the patient has.

For instance, stewardship programs can discourage doctors from bombarding patients with lots of different antibiotics. Instead, doctors can take an "antibiotic time out" until they get get lab results and reconsider their approach. (UCLA Health has a stewardship program in place.)

California last year mandated that hospitals create stewardship programs, but the federal government considers them voluntary. Even the Infectious Diseases Society of America was unable to determine how many hospitals have such a program, said John Billington, the society's director of health policy.

The Centers for Medicare & Medicaid Services has been taking a tougher line against hospital infections. Since October, more than 700 hospitals have been receiving lower payments from Medicare if they have higher rates of infections and other injuries. However, that program only tracks two kinds of catheter-related infections, not CRE. It will be two more years before the penalties incorporate rates from two antibiotic-resistant germs that have been around longer than CRE: C. diff., and methicillin-resistant Staphylococcus aureus, known as MRSA.

"A lot of patients are walking around with CRE and don't know about it," said Dr. Anthony Harris, president of the Society for Healthcare Epidemiology of America. "At this point CRE is still a fairly rare event, but this is the time to intervene so you don't have the magnitude of the problem we have with MRSA."

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Why California's Superbug Outbreak Isn't As Scary As It Seems

NPR Health Blog - Thu, 02/19/2015 - 9:44pm
Why California's Superbug Outbreak Isn't As Scary As It Seems February 19, 2015 9:44 PM ET

A particularly nasty family of gut bacteria with the nickname CRE is resistant even to carbapenems, a family of last-resort antibiotics.


News reports are describing a "nightmare superbug" killing people in California. But scientists who study infectious diseases say the risk from this outbreak doesn't live up to the alarming headlines.

"It's not something that is likely to spread around the community or is a cause for alarm," says David Perlin, an infectious disease scientist and executive director of the Public Health Research Institute at Rutgers.

A "superbug" outbreak suspected in the deaths of two patients at UCLA Medical Center has raised questions at the FDA: Are the standard procedures for disinfecting a particular kind of endoscope adequate?

Damian Dovarganes/AP

Here's what government health officials and the UCLA Health system have said so far:

Bacteria that are extremely resistant to drugs have infected at least seven patients who had endoscopic procedures at a teaching hospital affiliated with the University of California, Los Angeles. Two of the patients died and the UCLA Health System is notifying 179 patients that they may have been exposed.

The bacteria involved are known as Carbapenem-resistant enterobacteriaceae, or CRE, a family of bacteria that is highly resistant to even the toughest antibiotics. The infections in Southern California have been linked to two particular endoscopes, specialized devices that allow doctors to look inside the body without making an incision. These endoscopes have special features that allow doctors to diagnose and treat problems in the pancreas and bile ducts. UCLA says both of the instruments the hospital found to be contaminated are no longer in use.

The outbreak is a reminder of a serious underlying problem: the rise in dangerous drug-resistant germs, Perlin says. But it's unlikely to spread further because UCLA appears to have identified and eliminated the source of infection, he says.

Also, CRE bacteria aren't a threat to most healthy people, says Dr. Deverick J. Anderson, an infectious disease specialist and co-director of the Duke Infection Control Outreach Network. Studies show that many people carry CRE bacteria in their intestines and never know it because their immune system keeps the bugs in check, Anderson says.

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The people at high risk of damage from CRE are "very sick patients" in hospitals, nursing homes and long-term-care facilities, Anderson says. Often, the bacteria get into these people through breathing tubes, catheters or other medical devices that breach the body's usual protection from infection, he says. "It's not easily transmitted in a household."

The type of endoscope linked to the UCLA infections is called an ERCP duodenoscope. These endoscopes are "the medical equipment that are most commonly associated with [CRE] outbreaks," Anderson says, because they are especially hard to disinfect after each use.

But even with these devices, the risk of infection is low. ERCP duodenoscopes are used on more than 500,000 patients each year, according to the Food and Drug Administration. During 2013 and 2014, they were linked to 135 CRE infections.

On Thursday, the FDA issued a statement alerting health care professionals to the problem with "ERCP duodenoscopes." The agency urged people who work with the devices to "meticulously" clean them "prior to high-level disinfection."

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The news coverage and public's concern related to CRE are "going to flare up and then it's going to go away," says David Ropeik, a consultant in risk perception and communication. That's because this particular outbreak of this particular type of bacteria doesn't pose an immediate risk to most people, he says.

But "the world will still be at serious peril from a risk we don't take seriously, which is antibiotic resistance," he says. "Germs are figuring out how to resist our antibiotics faster than we can make new ones."

The problem of drug resistance is "almost all related to our antibiotic use" and overuse, Anderson says. Health organizations and the government, he says, have launched a number of efforts to prevent unnecessary prescribing.

But these efforts, Ropeik says, unlike disease outbreaks, rarely get much attention.

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A Biological Quest Leads To A New Kind Of Breast Cancer Drug

NPR Health Blog - Thu, 02/19/2015 - 4:05pm
A Biological Quest Leads To A New Kind Of Breast Cancer Drug February 19, 2015 4:05 PM ET Listen to the Story 5 min 10 sec  

It's a good start when experimental compounds stop the proliferation of cancer cells in the lab. But, as many researchers have learned the hard way, that's just an early step toward creating a worthwhile treatment.

Science Source

Each year, the Food and Drug Administration approves dozens of drugs, but often those medicines don't make a huge difference to people with disease. That's because these "new" drugs are often very much like existing medicines — or are, in fact, existing medicines, approved for a slightly different purpose.

But every now and then the FDA approves a truly new drug. And that's the story of Pfizer's palbociclib, brand name Ibrance, which the agency approved for the treatment of a common form of advanced breast cancer.

"What you're seeing here is a very important step in the right direction. But it's one step, and we have to follow the journey out to the very end, which is preventing metastasis as well as preventing cell division."

The story of this drug illustrates the challenging road that connects a fundamental discovery in biology to a pill that can make a difference.

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This pill's story began years ago in academic labs that were churning out the basic science that explains biology but rarely makes the headlines. Scientists who were trying to understand how healthy cells divide uncovered one critical step in that process, a step controlled by a set of enzymes known (for short) as CDK4/6.

Upon further investigation, researchers discovered that cancer cells sometimes use this enzyme system to spur cell growth and cell division in tumors.

Scientists at a company that is now part of Pfizer developed a chemical with promising properties: It seemed to shut down the CDK4/6 enzymes in cancer cells, without doing a lot of damage to healthy tissues. That chemical is the drug that became Ibrance. (A news article in Science magazine tells the full history).

The compound ended up as the property of Pfizer, which decided to see if it would be useful against cancer. The company provided the material and funding to academic labs that took the lead in exploring the chemical's potential. Drs. Richard Finn at the UCLA Geffen School of Medicine and his colleague Dennis Slamon at the Revlon/UCLA Women's Cancer Research Program decided to see if Pfizer's compound would be effective against breast cancer.

"The hypothesis going in was, 'If we could block the function of the CDK4/6 [enzymes], then we may stop cancer growth,' " Finn says. Lab tests showed that it didn't kill all breast cancer tumor cells in the lab, but it did kill one common subtype.

"That's not something that we thought of, going into the study," Finn says. "We weren't really exactly sure where it would work."

Dr. Richard Finn (right) at the UCLA Geffen School of Medicine and his colleague Dr. Dennis Slamon at the Revlon/UCLA Women's Cancer Research Program.


Through that trial-and-error lab work, they found that the drug killed the type of breast cancer cells whose growth is fueled by the hormone estrogen.

Women who have advanced stages of this type of cancer are usually treated with drugs that block estrogen. But eventually those drugs lose their potency. The cancer finds a workaround, like a driver who heads onto side streets when the main drag is clogged with traffic.

Scientists thought that a side street in this case might be the CDK4/6 pathway. If that were true, Ibrance would help stop malignancies that had become resistant to estrogen-blocking drugs.

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So Finn headed up a study that recruited 180 women with advanced, estrogen-dependent breast cancer. About half got the standard drug that blocks estrogen, and the other half got that standard drug plus Ibrance.

Among women taking the conventional drug, the scientists found that the disease started to progress again after an average of 10 months. The women taking both drugs went an average of 20 months before their cancer started to progress.

Whether that use of Ibrance extends a woman's life is still an open question. "So far we have not seen a statistical difference in survival," Finn says, "but that will continue to be followed."

On the basis of this small study, the FDA provisionally approved Ibrance for use in this type of advanced cancer among women who are postmenopausal. The FDA is now awaiting results from larger studies, and is prepared to revoke its approval if the drug doesn't prove effective in this larger population.

But Finn is hopeful that further studies will find that the drug is useful in other situations — maybe even among women who are diagnosed early in the course of their disease.

"Perhaps in the early breast cancer setting, that might translate into getting rid of chemotherapy in those women," Finn says. "And that would be a huge advance, as well as improving survival.

Pfizer is also studying the drug to see if it might be effective against several other cancers, including lung cancer, melanoma and prostate cancer.

Killing malignant cells is, of course, a vital part of treating cancer. But it's just one component in the optimal treatment strategy.

"Nobody ever died of cancer cells," says Dr. Larry Norton at the Memorial Sloan Kettering Cancer Center. "You die of tumors."

And tumors aren't just cancer cells. They have their own blood supply. They prevent the immune system from removing runaway growths. And, what's really deadly: Tumors seed elsewhere in the body; they metastasize.

"So what you're seeing here is a very important step in the right direction," Norton says, "but it's one step, and we have to follow the journey out to the very end, which is preventing metastasis as well as preventing cell division."

That strategy also means identifying and shutting down many different avenues of escape. And each new drug to do that costs a lot. Pfizer has priced Ibrance at $118,000 a year (though some patients may be eligible for financial assistance). Multiply that by several drugs to treat a single case of cancer, and the price escalates accordingly.

"We [in the cancer treatment community] know that's an issue that's going to have to be addressed," Norton says. "We're trying to address it in many, many different ways. And clearly, for the sake of all humans who could get cancer and should have access to the best drugs, it's a problem we're going to have to solve."

And of course there are many other problems of basic biology to solve. Scientists don't have a way to block all the alternate routes that cancer can take. But Norton sees progress.

"I've been doing oncology long enough that I've seen cancers go from incurable to curable at the right moment in history," he says. "It could happen to breast cancer in years; it could happen to breast cancer in days to weeks. We don't know when it's going to happen."

The history of the war on cancer is full of promises that success is just around the corner. It turns out there have been a lot of corners. Success has been incremental, but sometimes those increments add up. That's a major reason breast cancer death rates in the United States are gradually falling.

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Just A Bit Of DNA Helps Explain Humans' Big Brains

NPR Health Blog - Thu, 02/19/2015 - 1:48pm
Just A Bit Of DNA Helps Explain Humans' Big Brains February 19, 2015 1:48 PM ET Listen to the Story 4 min 27 sec  

Scientists studying the difference between human and chimpanzee DNA have found one stretch of human DNA that can make the brains of mice grow significantly bigger.

"It's likely to be one of many DNA regions that's critical for controlling how the human brain develops," says Debra Silver, a neurobiologist at Duke University Medical School.

The human version of a DNA sequence called HARE5 (inserted into this mouse embryo) turned on a gene that's important for brain development. (Gene activity is stained blue.) By the end of gestation, the embryo's brain was 12 percent larger than the brain of an embryo injected with the chimpanzee version of HARE5.

Silver Lab/Duke University

It could also help explain why human brains are so much bigger than chimp brains, says Silver, who notes that "there are estimates of anywhere from two to four times as big."

In addition to having bigger brains, Silver says, humans also "have more neurons, and we have more connections between these neurons."

Scientists would like to understand what the genetic basis is for humans' apparently special capacity for logic, abstract thought, complex emotions and language. Humans and chimpanzees have DNA that's remarkably similar — researchers say our genetic code is about 95 percent identical. But Silver and some colleagues recently started looking at pieces of DNA that differ markedly between chimps and humans.

"We went through those and picked out ones that seemed to be likely to be regulating gene activity in a developing brain," explains Silver.

One stretch of DNA looked promising because it was near a gene that's known to be involved in brain development. The researchers took the chimp version of this DNA and put it into mouse embryos. They took other mouse embryos and put in the human version.

"What we discovered is that the human DNA turned on gene activity in neural stem cells, and these are cells which produce the neurons of our cerebral cortex," says Silver.

Just before birth, mice with the human DNA had brains that were noticeably larger — about 12 percent bigger than the brains of mice with the chimp DNA, according to a report in the journal Current Biology.

"We were really excited when we saw the bigger brains," Silver says. Her team now wants to know if the mice will behave differently in adulthood. They're also looking for other bits of uniquely human DNA that affect the brain. "We think this is really the tip of the iceberg," she says.

The particular region of DNA they found to be important is in a part of the genetic code that was once called "junk DNA." This is DNA that doesn't code for proteins, so scientists used to think it served no purpose. These days, researchers believe this kind of DNA probably regulates how genes get turned on and off — but what exactly is happening there is still mysterious.

"We can now actually generate the equivalent of embryonic brain cells and tissues that are human or chimpanzee. And, using genome engineering techniques, we can start to study the effects of switching the human and the chimp sequences in these primate cell lines."

"We have very little scientific information about the actual functions of those regions," says Katie Pollard, who studies human and chimp DNA at the Gladstone Institutes and the University of California, San Francisco.

Most of the genetic differences between humans and chimps are actually found in the so-called junk DNA, Pollard notes. "While it's now pretty easy to find the genetic differences, it's very challenging to figure out exactly whether those differences made a change in a trait, and why."

This new study, says Pollard, "is helping to try to bridge that gap."

She called the bigger brains seen in the mice "intriguing" but said the effect it might have on the animals' cognition would be difficult to predict.

In this field of study, she says, one of the challenges has been that scientists would like to be able to make a genetic change and show that it really makes a difference. "But we're talking about humans and chimpanzees here, and you cannot experiment on either of those," she notes. "And so it's very challenging to prove causation."

In Pollard's lab, scientists are exploring the differences between chimp and human DNA using dishes of cells.

"We can now actually generate the equivalent of embryonic brain cells and tissues that are human or chimpanzee," says Pollard. "And, using genome engineering techniques, we can start to study the effects of switching the human and the chimp sequences in these primate cell lines."

Eventually, work like this could generate a list of DNA sequences that give a brain some capabilities that are characteristically human. That could be important for understanding what goes wrong in diseases of the brain. But could someone use that information to make the brains of a nonhuman species more like us — to create the kind of superchimps that mocked humans in the Planet of the Apes?

"One can never say never, but I think it's a pretty long-shot, far-fetched type concern," says Ruth Faden, who directs the Johns Hopkins Berman Institute of Bioethics.

An experiment like this recent one is not going to create mice that talk and think like people, Faden says. But it could be more ethically worrisome to try to genetically enhance the brains of nonhuman primates or other reasonably intelligent animals — like pigs.

That's something our own species might prefer to avoid, says Faden. "The prospect of, sort of, tearing down the barriers between humans and other nonhuman species in ways that really threaten our sense of ourselves as special is disturbing," she points out.

Even though any possibility like that would be far, far in the future, Faden says it's not too soon to start thinking about it.

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Humana Discloses Widening Justice Dept. Probe Of Medicare Advantage Plans

NPR Health Blog - Thu, 02/19/2015 - 1:37pm
Humana Discloses Widening Justice Dept. Probe Of Medicare Advantage Plans February 19, 2015 1:37 PM ET Fred Schulte

Health insurer Humana Inc. disclosed that its Medicare Advantage plans are being looked at by the feds.

Brian Bohannon/AP

Humana, Inc. faces new scrutiny from the Justice Department over allegations it has overcharged the government by claiming some elderly patients enrolled in its popular Medicare plans are sicker than they actually are.

The Louisville, Ky.-based insurer disclosed the Justice Department's recent civil "information request" in an annual report filed with the Securities and Exchange Commission on Feb. 18. The company noted that it is cooperating with authorities.

"We continue to cooperate with and voluntarily respond to the information requests from the Department of Justice and the U.S. Attorney's Office," Humana wrote.

The privately run Medicare Advantage plans offer seniors an alternative to standard Medicare, which pays doctors for each service they render. By contrast, under Medicare Advantage, the health plans are paid a set fee monthly for each patient based on a complex formula known as a risk score. Essentially, the government pays higher rates for sicker patients and less for those in good health.

Shots - Health News Fraud Case Casts Spotlight On Medicare Advantage Plans

But overcharges related to inflated risk scores, intentional or not, have cost taxpayers billions of dollars in recent years, as the Center for Public Integrity reported in a series published last year.

The Center first disclosed multiple investigations of the Humana Medicare Advantage plan last May based on records filed by the U.S. Attorney's Office in Miami in a civil suit.

More Scrutiny Coming For Medicare Advantage, Obamacare Nov. 4, 2014

But Humana's financial disclosure offers fresh details into the wide scope of the Justice review, indicating it is taking aim at a range of common Medicare Advantage billing practices and fraud controls, as well as Humana's use of home health assessments of patients in its plans. The industry argues these "house calls" improve the health of elderly patients, but federal officials have been concerned that the primary objective is to raise risk scores and revenues.

Humana said the Justice Department had requested a range of records about "our business and compliance practices related to risk adjustment data generated by our providers and by us, including medical record reviews conducted as part of our data and payment accuracy compliance efforts, the use of health and well-being assessments, and our fraud detection efforts."

The government probe comes at an inopportune time for the burgeoning Medicare Advantage industry, which is mounting an intense lobbying and advocacy effort to stave off proposed government funding cuts.

The Centers for Medicare and Medicaid Services is set to release proposed funding levels for 2016 on Friday. More than 16 million seniors have joined these private health plans. Humana has enrolled about 3.2 million people in Medicare Advantage plans.

What will happen to the rates is not yet clear. But the Obama administration's 2016 budget seeks to cut some $36 billion from Medicare Advantage plans over the next decade related to oversized risk scores.

Allegations that some Medicare Advantage plans manipulate risk scores, a process known in the industry as "upcoding," have been surfacing over the past year in the federal courts.

The Center for Public Integrity has previously reported on several of these whistleblower lawsuits, including one filed by a Miami doctor against Humana.

In that case, Olivia Graves alleges that a Humana medical center had diagnosed abnormally high numbers of patients with diseases such as diabetes with complications that boosted Medicare payments — diagnoses that "were not supported by medical records." Graves alleges that Humana knew about the overcharges but took no action to stop them. Humana has denied the allegations.

And in early February, a federal grand jury in West Palm Beach, Fl. indicted Dr. Isaac Kojo Anakwah Thompson on eight counts of health care fraud. He's accused of cheating Medicare out of about $2.1 million by inflating risk scores of some Humana-enrolled patients. Thompson, 55, is free on a $1 million bond and has declined comment through his lawyer.

The Florida indictment did not accuse Humana of wrongdoing, but company spokesman Tom Noland said that it had repaid the government. He declined to say how much.

New scrutiny of home visits also could prove troublesome for the industry. At least one whistleblower, a former manager at a California firm that does medical home visits, has alleged that the process was abused to inflate risk scores.

Humana has been a major promoter of these home assessments. In an email to the Center today, Noland wrote: "We believe in continuing to do in-home assessments as we see this as an important step in establishing care management plans for our members living with multiple chronic conditions."

Noland declined to say how many of the home assessments Humana has performed. But the company has previously said that it conducted the assessments for about 531,000 members in the first three months of 2014.

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. To follow CPI's investigations into Medicare and Medicare Advantage waste, fraud and abuse, go here.

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Why A Court Once Ordered Kids Vaccinated Against Their Parents' Will

NPR Health Blog - Thu, 02/19/2015 - 3:23am
Why A Court Once Ordered Kids Vaccinated Against Their Parents' Will February 19, 2015 3:23 AM ET Listen to the Story 4 min 23 sec  

Measles is highly contagious, and it produces fever and rash in susceptible people who become infected.

Hazel Appleton/Health Protection Agency Centre/Science Source

A highly contagious disease was sweeping across the United States. Thousands of children were sick and some were dying. In the midst of this outbreak, health officials did something that experts say had never been done before and hasn't been done since: They forced parents to vaccinate their children.

It sounds like something that would have happened 100 years ago. But this was 1991 — and the disease was measles.

Dr. Robert Ross was deputy health commissioner of the hardest-hit city, Philadelphia, where the outbreak was centered in the Faith Tabernacle Congregation in the northern part of town.

"This church community did not believe in either immunizations or medical care," says Ross, who is now the president of the California Endowment, a private health foundation.

The church ran a school with about 1,000 kids. Ross says that none had been vaccinated. One day, his office got a phone call from a grandparent, saying that a lot of children at the school were sick. They had developed rashes from head to toe and fevers — telltale signs of measles.

Ross and his colleagues approached the church and pleaded with the pastor to allow health officials to examine and immunize the children. But the pastor refused. So Ross and his colleagues went door to door, to church members' homes.

He says that most of the parents were pleasant and cooperative and allowed health officials to enter their homes. Many of the children they saw had measles. Ross says the majority were doing fine, but some were very sick, including an 8-year-old girl.

"[She] was lying on the couch in front of the television, ashen and pale, and with a very rapid respiratory rate. I felt that she may die within hours if we didn't get her to treatment," Ross says.

He went to the family's living room to call a judge, who was on call and ready to issue a court order, requiring any gravely ill children to be taken to a hospital. But as Ross held the phone, the girl's grandmother grabbed his arm and tried to prevent him from dialing.

"She began lecturing me about believing in the power of the Lord," Ross says. "It was a viscerally disturbing episode that left me quite shaken."

Ross eventually reached the judge, and the girl was taken to a local hospital. She survived.

But across the city, hundreds more were sick. So Ross and his colleagues did something unprecedented: They got a court order to force parents at Faith Tabernacle to have their children vaccinated.

Ross says it was the right thing to do, because it was in the best interest of the children. But it was deeply traumatizing to the parents.

"I recall we lined the children up and gave the immunizations, and many of the parents were actually weeping," he says.

The court order had taken a few weeks. By the time the vaccines were administered, the measles outbreak was subsiding in Philadelphia. Only nine children from the church were ultimately vaccinated, and Ross says the intervention probably didn't affect the spread of the disease.

In the end, nine kids across Philadelphia died, including six from Faith Tabernacle. The church is still operating the school today but declined to comment.

Some experts say it's rather surprising that the parents were forced to have their children vaccinated.

"There was a law that protected these church members' right to refuse vaccination on religious ground," says Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia.

Paul Offit On The Anti-Vaccine Movement 17 min 43 sec  

But the U.S. Supreme Court had ruled years earlier that parents cannot deny lifesaving medical treatments to their children for religious reasons. That ruling set a precedent that made it difficult for Faith Tabernacle to find legal representation.

"Even the American Civil Liberties Union, which was perfectly willing to represent an unpopular cause, declined to take the case, because they felt that it was not [the parents'] right to martyr their children to their beliefs," Offit says.

So the question now is this: If there were a similar outbreak today, could the courts force parents to vaccinate their children?

Offit says it's possible. "Were things ever to get as bad, even approaching as bad as things were in Philadelphia in 1991, yes, there are certainly legal remedies to make sure that we can compel parents to protect their children," he says.

Ross, who led the fight against measles in Philadelphia, says health officials must go to great lengths to educate parents about the importance of vaccines. He believes courts should only intervene when parents are clearly putting their children's lives at risk.

"It should be 'break glass in case of emergency,' " he says.

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Pain Really Is All In Your Head And Emotion Controls Intensity

NPR Health Blog - Wed, 02/18/2015 - 4:03pm
Pain Really Is All In Your Head And Emotion Controls Intensity February 18, 2015 4:03 PM ET Listen to the Story 4 min 14 sec   iStockphoto

When you whack yourself with a hammer, it feels like the pain is in your thumb. But really it's in your brain.

That's because our perception of pain is shaped by brain circuits that are constantly filtering the information coming from our sensory nerves, says David Linden, a professor of neuroscience at Johns Hopkins University and author of the new book Touch: The Science of Hand, Heart, and Mind.

"There is a completely separate system for the emotional aspect of pain — the part that makes us go, 'Ow! This is terrible.' "

"The brain can say, 'Hey that's interesting. Turn up the volume on this pain information that's coming in,' " Linden says. "Or it can say, 'Oh no — let's turn down the volume on that and pay less attention to it.' "

This ability to modulate pain explains the experiences of people like Dwayne Turner, an Army combat medic in Iraq who received the Silver Star for valor.

In 2003, Turner was unloading supplies when his unit came under attack. He was wounded by a grenade. "He took shrapnel in his leg, in his side — and he didn't even notice that he had been hit," Linden says.

Despite his injuries, Turner began giving first aid and pulled other soldiers to safety. As he worked, he was shot twice — one bullet breaking a bone in his arm. Yet Turner would say later that he felt almost no pain.

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"Soldiers in the heat of the moment don't recognize the pain that's happening," Linden says. But once that moment is over, those same soldiers may feel a lot of pain from something minor, like a hypodermic needle, he says.

The brain also determines the emotion we attach to each painful experience, Linden says. That's possible, he explains, because the brain uses two different systems to process pain information coming from our nerve endings.

One system determines the pain's location, intensity and characteristics: stabbing, aching, burning, etc.

"And then," Linden says, "there is a completely separate system for the emotional aspect of pain — the part that makes us go, 'Ow! This is terrible.' "

Linden says positive emotions — like feeling calm and safe and connected to others — can minimize pain. But negative emotions tend to have the opposite effect. Torturers have exploited that aspect for centuries.

"If they want to accentuate pain during torture they can do this with humiliation [or] with an unpredictable schedule of delivering pain," Linden says. "Those things will make the emotional component of the pain experience stronger."

CIA interrogators used both tactics after Sept. 11, according to a Senate report released late last year.

One thing scientists are still trying to understand is precisely how the brain regulates the perception of pain. A team from Brown University has found some clues.

The team studied low-frequency brain waves in a part of the brain that responds to sensations in the hand, says Stephanie Jones, an assistant professor of neuroscience at Brown. Earlier research had shown that these rhythms increase when the brain is blocking sensory information from the hand.

Author Interviews Living With Chronic Pain 'In The Kingdom Of The Sick'

But what causes these rhythms to increase? The team thought it might find an answer in a frontal area of the brain that helps us ignore distractions.

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So the reseasrchers monitored the brain waves of a dozen people who were asked to pay attention only to their hand or only to their foot. During the experiment the scientists delivered a light tap to each person's finger or toe.

When participants focused on their feet, low-frequency rhythms increased in the brain area that responds to hand sensations — because participants were asking their brains to ignore sensory input from the hand, and it's these low-frequency rhythms that do the blocking of such information. That was expected.

But low-frequency rhythms also increased in a different brain area — the region that ignores distractions, the team discovered. They reported their findings in the current issue of The Journal of Neuroscience.

The two areas became synchronized, Jones says. "There's coordination between the front part of the brain, which is the executive control region of the brain, and the sensory part of the brain, which is filtering information from the environment," she says.

That suggests that at least some people can teach their brains how to filter out things like chronic pain, perhaps through meditation, Jones says.

A 2011 study supports this idea. It found that people who practiced mindfulness meditation for eight weeks greatly improved their control of the brain rhythms that block out pain.

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Pregnant And Uninsured? Don't Count On Obamacare Coverage

NPR Health Blog - Wed, 02/18/2015 - 9:37am
Pregnant And Uninsured? Don't Count On Obamacare Coverage February 18, 2015 9:37 AM ET

Partner content from

Phil Galewitz

Under the Affordable Care Act, pregnancy isn't considered a "qualifying event" that justifies enrollment at any time.


The Obama administration often touts the health benefits women have gained under the Affordable Care Act, including the option to sign up for coverage outside of open enrollment periods if they're "having a baby."

But advocates complain that the special insurance enrollment period begins only after a birth. As a result, uninsured women who learn they are pregnant outside of the regular three-month open enrollment period, which this year ended Sunday, can get stuck paying thousands of dollars for prenatal care and delivery — or worse, going without care.

The advocacy groups, including the March of Dimes, Planned Parenthood and Young Invincibles, are asking the administration to allow women to sign up whenever they become pregnant.

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"If you have to spend $10,000 to $20,000 out of pocket on maternity care, it certainly puts women in a difficult position and insurance coverage [after a child's birth] would be coming too late for them," said Christina Postolowski, health policy manager for Young Invincibles, a nonprofit that has worked with the administration to boost enrollment.

The group released a report Wednesday that looks at the economic and health consequences of not making pregnancy "a qualifying event" to sign up for coverage any time.

Without access to a health plan, women may be more likely to forgo prenatal care because they can't afford it, which can put them at higher risk for conditions than can affect their own health as well as that of their child, such as pregnancy-related diabetes and high blood pressure, the report said.

About half of pregnancies are unintended, notes Cynthia Pellegrini, senior vice president of the March of Dimes. And women often can't predict when they will have a challenging pregnancy requiring more services.

Shots - Health News Health Law's Big Tent Still Leaves Some People Out

The advocates have applauded the health law for including maternity coverage among the list of "essential benefits." But they say that allowing women to get covered as soon as they're pregnant would give them and their unborn children greater protection. It would also allow those with high-risk pregnancies to change plans to get more comprehensive coverage that might include access to certain hospitals and doctors.

But the health insurance industry contends that allowing reproductive-age women to enroll any time they become pregnant would give women an incentive to wait to buy coverage.

"If you only create incentives for people to enroll when they have a health need, it poses a tremendous risk to the risk pool and affordability for everyone else," said Clare Krusing, a spokeswoman for America's Health Insurance Plans, the industry's trade group. She said insurers would have more difficulty setting their prices because it would be harder to predict who would buy coverage.

Court Rejects Challenge To Obamacare Rules On Contraceptives

Before the Affordable Care Act, individual insurance policies rarely included maternity coverage — and women could not buy policies after they became pregnant. Today, they can buy such coverage during open enrollment.

Updated 2/18/15 3:37 EST: In a statement Wednesday, HHS Secretary Sylvia Mathews Burwell said the department has not included pregnancy as a qualifying life event because "we have based it on how insurance companies made the determinations when they have periods for open enrollment or not."

But HHS is open to considering the issue, she said.

The Obama administration allows people to enroll outside of the regular enrollment period in several circumstances, including after adopting or having a child, losing other coverage, moving out of a plan's service area or getting married.

This list of so-called "qualifying events" is similar to the circumstances that allow people with employer-sponsored insurance to change their coverage outside of open enrollment. The administration last week said it was considering adding a special enrollment period for people who discover they owe a tax penalty due to lack of coverage.

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Kids' Solo Playtime Unleashes 'Free-Range' Parenting Debate

NPR Health Blog - Wed, 02/18/2015 - 4:36am
Kids' Solo Playtime Unleashes 'Free-Range' Parenting Debate February 18, 2015 4:36 AM ET Listen to the Story 4 min 15 sec  

People who practice free-range parenting say it makes kids more independent, but others see it as neglect. State and local laws don't specify what children are allowed to do on their own.


Parents have made news recently after being detained for purposefully leaving children on their own, prompting renewed debate about so-called "free-range parenting."

That includes Danielle and Alexander Meitiv, a Silver Spring, Md., couple who are being investigated after they let their children, ages 10 and 6, walk home from a park last month by themselves.

Moms and dads who practice this parenting style say it promotes independent, even fearless kids. But what is considered free-range by some can look like neglect to others. As for what's against the law, child welfare experts say there's no easy answer.

$(function() { var pymParent = new pym.Parent( 'responsive-embed-table-free-range-kids', '', {} ); }); Additional Information: Parenting Independence For Kids: When To Give It And How Much All Tech Considered Parent Over Shoulder: Apps Help Mom Snoop Online, But Should She? Shots - Health News Anxious Parents Can Learn How To Reduce Anxiety In Their Kids

In Austin,Texas, last year, Child Protective Services showed up after a 6-year-old was reported to be playing alone in a field 150 yards from his house. His mom, Kari Anne Roy, told CBS This Morning she was shocked.

"If CPS gets a call, you want them to check on the welfare of the children," she says. "However, I think that when they're getting these kinds of frivolous calls it's wasting resources."

But Christine James-Brown, president and CEO of the Child Welfare League of America, says while some investigations will inevitably prove a waste in the end, that doesn't mean agencies should forgo them.

"The first responsibility is to that child," she says. "So let's not let all this free-range stuff get in the way just because it looks like this mother's OK. 'Cause there are lots of people where it's not OK."

Most child welfare cases today are for neglect, not abuse. As for allowing kids out without supervision, few states set a strict minimum age, instead advising parents to use their judgment. Parents must ask themselves, is my child mature? Do they know how to call 911? How to reach a parent?

"The way neglect is defined in the law, it's a very vague definition, it kind of has to be," says John Myers, who teaches family law at the University of the Pacific in Sacramento, Calif., and represents children in juvenile court.

A 10-year-old may be perfectly fine walking alone in one neighborhood, he says, but might not be safe in another with drug dealers on the corner.

"Parents who live in poverty are more likely to be helicopter parents."

"We hate to say that the people that live in those two communities ought to be treated differently because we would probably get into uncomfortable issues of socioeconomic status and ethnicity," he says. "But that's the reality in our country."

Myers sees a clear link between poverty and what some may consider neglect. Last year, a single mother in South Carolina was arrested for letting her daughter play in a park while she worked at McDonald's. Myers says working parents — with no money for a sitter, no car, no spouse — may well leave kids alone out of necessity. But it doesn't mean they don't care.

"If anything, parents who live in poverty are more likely to be helicopter parents," he says. "They're more worried about their children when they go to school, whether they'll be sucked into gang life, teaching them how to duck when they hear gun fire and all kinds of stuff, because they understand some of the risks their children may be exposed to."

Safe neighborhood or not, James-Brown says attitudes have changed. As a child, she walked to school alone and neighbors looked out for her. When she became a mom, James-Brown tried to do the same, once warning another dad that his daughter was dodging cars in a street game of chicken.

"Well, the parent laid me out," she says. "And so what is it now about our communities that that would happen? You know, you go from the expectation that somebody's gonna tell Mom, to if told, they'd be viewed as busybodies."

Communities today may be made up of strangers, but James-Brown says they still have a stake in how kids are raised and a role to play in keeping them safe. She hopes all the media scrutiny gets more people thinking about what that role should be.

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Many Parents Aren't Sold On Later School Start Times For Teens

NPR Health Blog - Tue, 02/17/2015 - 1:59pm
Many Parents Aren't Sold On Later School Start Times For Teens February 17, 2015 1:59 PM ET

The American Academy of Pediatrics says middle and high schools shouldn't start before 8:30 a.m., so students can get enough sleep.


Sleeping in probably sounds like a no-brainer to most teenagers, but their parents aren't so sure that it's worth starting school later to get the extra shut-eye.

Shots - Health News Pediatricians Say School Should Start Later For Teens' Health

Half of parents with teenagers whose schools start before 8:30 am said they would like schools to start after that, according to a survey released Monday by C.S. Mott Children's Hospital in Michigan. The later start time was recommended last August by the American Academy of Pediatrics, with the goal of at least 8 1/2 hours of sleep a night for teens.

Shots - Health News Parents Of Sleep-Deprived Teens Push For Later School Start Times

The pediatricians say more sleep will improve mood and academic performance, and reduce the risk of traffic accidents and obesity.

But just 40 percent of the parents said they thought the shift would mean kids would get more sleep; 20 percent said they thought it would improve academic performance.

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The survey doesn't clarify why parents aren't so keen on later starts for middle school and high school. But 22 percent of the 636 parents surveyed said they thought the later start would not allow enough time for afterschool activities.

Shots - Health News Less Sleep, More Time Online Raise Risk For Teen Depression

About half of the parents who favored later start times said they thought the shift should be made only if it didn't impact the school budget.

Sounds like a ringing endorsement of "Hmm," doesn't it?

But it turns out that just 20 percent of the parents had heard about the pediatricians' new policy. Once the surveyors explained it, 71 percent of parents said they agreed with it.

So maybe what we have here is a need for some education, at least when it comes to pediatricians and parents.

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Figuring Out If A Doctor Is In Your Network Can Be Perplexing

NPR Health Blog - Tue, 02/17/2015 - 9:44am
Figuring Out If A Doctor Is In Your Network Can Be Perplexing February 17, 2015 9:44 AM ET

Partner content from

Michelle Andrews

"Is this doctor in my insurance network?" is one of the key questions people ask when considering whether to see a particular doctor. Unfortunately, in some cases the answer may not be a simple yes or no.

That's what Hannah Morgan learned when her husband needed surgery last fall to remove his appendix. When they met with the surgeon at the hospital emergency department near their Lexington, Ky., home, Morgan asked whether he was in the provider network for her husband's individual policy, which he bought on the Kentucky health insurance exchange. The surgeon assured her that he was. When she got home, Morgan confirmed that he was in network using the online provider search tool for her husband's plan.

But when she read the explanation of benefits form from the insurer, the surgeon's services were billed at out-of-network rates, leaving the couple on the hook for $747.

The surgeon's office later told her that he belonged to two different medical groups. One was in Morgan's husband's health plan network, the other wasn't. Following multiple phone conversations with the surgeon's office and the insurer, the in-network rates were applied and the Morgans' share of the bill shrunk to $157.

"I did everything I was supposed to do," says Morgan, 26. "You feel kind of hopeless. I thought I did it right, and there's still another hoop to jump through."

Consumers who use out-of-network providers can rack up huge bills, depending on the care required. Health maintenance organizations generally don't cover any non-emergency services provided by physicians or hospitals outside the plan's network of providers. Preferred provider organizations typically do cover out-of-network services, but pay a smaller percentage of the charges, 70 percent instead of 80 percent, for example. Out-of-network services may have higher deductibles and higher out-of-pocket maximums as well.

Although it's not routine, physicians can belong to more than one medical group. Surgeons, for example, may join a couple of medical groups to expand the number of hospitals that they're affiliated with.

Even then, sussing out in-network providers may not be straightforward. Just because a medical group is in someone's provider network, consumers can't be confident that all the physicians in the medical group are also in network.

Consumer advocates say the lack of transparency is unfair to consumers.

"It's 2015. Federal law requires Americans to buy health insurance," says Mark Rukavina, a principal at Community Health Advisors in Chestnut Hill, Mass. "There's something fundamentally wrong when you can only figure out what questions to ask after the fact."

In addition to confusion about doctors who are part of more than one practices, consumers may also run into billing troubles if their doctor operates practices in different locations and accepts different insurance plans at each.

If the physician's office submits the paperwork to the insurer with the tax identification number for the wrong office location, the patient may get hit with an out-of-network charge. In that case, the patient may have to contact the doctor's staff and ask them to resubmit the charges through the other practice.

Adding to the confusion is the fact that even if a physician is in a consumer's insurance network, the hospital or clinic she works at may not be or vice versa.

More consumers may face out-of-network problems as health plans shrink the size of their provider networks in an effort to keep costs down.

"Health plans work very hard to see that consumers have the information they need and resources to turn to when they have questions," says Susan Pisano, a spokesperson for America's Health Insurance Plans, a trade group. She noted that the Healthcare Financial Management Association and AHIP's foundation have online guides to help consumers. Still, she added, "There is clearly also a responsibility on the part of providers to be more transparent."

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Female Libido Pill Fires Up Debate About Women And Sex

NPR Health Blog - Mon, 02/16/2015 - 4:00pm
Female Libido Pill Fires Up Debate About Women And Sex February 16, 2015 4:00 PM ET Listen to the Story 6 min 48 sec   Maria Fabrizio for NPR

For 15 years, Carla Price and her husband's sex life was great. But then things began to change.

"Before, I would want to have sex," says Price, who is 50 and lives in central Missouri. "But over the years my sexual desire has just dwindled to nothing."

Price has no idea why. She's healthy. She's not really stressed out about anything. And she's still totally crazy about her husband.

"It's not that our relationship got boring," Price says. "Because it's actually the opposite — we became closer as we got older together."

"We live in a culture that has historically discounted the importance of sexual pleasure and sexual desire for women."

Movies In Quest For A Female Viagra, Many An Odd Twist

But her lack of interest in sex almost wrecked their marriage.

"It did get to the point where my husband thought that perhaps we just needed to divorce," she says.

Women like Price, who see their decreasing sex drive as a problem, are at the center of an intense, emotional debate that's been raging for years over whether the Food and Drug Administration should approve the first drug that claims to boost a woman's libido.

NPR reached Price through Sprout Pharmaceuticals Inc., the company that makes the drug.

"Men have a number of treatment options for sexual dysfunction, says Cindy Whitehead, Sprout's CEO. "We haven't yet gotten to one for women's most common dysfunction."

"Up until now," she says, "the treatment paradigm for women with sexual dysfunction has essentially been: Let's take a drug that works in men and let's see if it works in women."

"The misrepresentation that 'everybody should be having it, ... has a problem if they don't have it,' is to change what sexuality is into more of a medical thing."

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None of them did. But Sprout's drug, flibanserin, takes a totally different approach than, say, Viagra. Instead of increasing blood flow to the genitals, flibanserin affects a different part of the body: the brain.

Flibanserin shifts the balance of three key brain chemicals, Whitehead says. The drug, she says, increases "excitatory factors for sex" — dopamine and norepinephrine — and decreases serotonin, which can dampen the sex drive.

But there's a lot of skepticism about flibanserin. The FDA has rejected it twice, saying there wasn't much evidence it works. The agency also questioned the drug's safety, especially with long-term, daily use.

"The combination of ... not very robust effectiveness, and the fact that the safety profile had not been really characterized very well at all made us reach that conclusion, that it really wasn't ready for approval," says Sandra Kweder, deputy director of the FDA's Office of New Drugs.

The company acknowledges flibanserin can have side effects, including sleepiness, nausea and dizziness. And there are no results yet, Sprout says, on whether the drug might interfere with the helpful action of Zoloft, Prozac or other SSRI antidepressants, which are thought to work primarily by boosting levels of serotonin in the brain.

"Women ... want drugs that work. And this doesn't seem to be one of them."

But Whitehead argues that flibanserin is safe and says the company's studies show it can help many women.

"We increase their desire by 53 percent," she says of study participants. "We decrease their distress by 29 percent, and then they doubled their number of satisfying sexual events."

Whitehead argues the FDA is holding flibanserin to a higher standard than it uses to evaluate drugs for men. And some women's rights advocates worry that might be true.

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"We live in a culture that has historically discounted the importance of sexual pleasure and sexual desire for women," says Terry O'Neill, president of the National Organization for Women. "And I fear that it's that cultural attitude that men's sexual health is extremely important, but women's sexual health is not so important. That's the cultural attitude that I want to be sure the FDA has not, maybe unconsciously, imported into its deliberative process."

Author Interviews Lena Dunham On Sex, Oversharing And Writing About Lost 'Girls'

The FDA denies any bias.

"We have taken those concerns very seriously and we think the accusation is truly misplaced," Kweder says.

Many other women's health advocates agree with the agency's caution.

"It doesn't seem to work very well, if at all, and it's got some safety concerns that are troubling and haven't been fully explored," says Cindy Pearson of the National Women's Health Network. "So we felt very comfortable saying to the FDA, 'You know, women want attention, but they want drugs that work. And this doesn't seem to be one of them.' "

Others argue that the campaign for flibanserin is oversimplifying female sexuality. And many women (and men) who experience a waning libido at midlife don't see it as a problem.

"The misrepresentation that everybody should be having it — needs to have it, wants to have it, has a problem if they don't have it — is to change, really, what sexuality is into more of a medical thing," says Leonore Tiefer, a psychologist at New York University. "I think that's a terrible direction for knowledge, for understanding, for society."

Some say Sprout's campaign is part of a bigger trend by the pharmaceutical industry to turn everything into a disease that needs a pill.

"There's really been a move toward medicalizing normal human experience," says Adriane Fugh-Berman, who studies drug companies at Georgetown University. "And while there are certainly some women who have very troublesome symptoms of low libido, it's not at all clear that medication is a good answer for them."

A low libido may be a symptom of fluctuating hormones or of some health problem that needs attention. Some women may just be in a bad relationship. For others, therapy might be the answer.

Carla Price says she would like to try flibanserin. Marriage counseling and a hormonal cream have helped, she says. But not enough.

"Even though it's better, it's not perfect," she says. "I would gladly take risks of side effects to keep my marriage and my relationship."

Sprout says the company plans to submit some new studies soon that it hopes will finally convince the FDA to approve the first drug to boost a woman's libido.

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Satisfied Patients Now Make Hospitals Richer, But Is That Fair?

NPR Health Blog - Mon, 02/16/2015 - 3:44am
Satisfied Patients Now Make Hospitals Richer, But Is That Fair? February 16, 2015 3:44 AM ET


Michael Tomsic Listen to the Story 3 min 50 sec  

In Medical Park Hospital in Winston-Salem, N.C., Angela Koons is still a little loopy and uncomfortable after wrist surgery. Nurse Suzanne Cammer gently jokes with her. When Koons says she's itchy under her cast, Cammer warns, "Do not stick anything down there to scratch it!" Koons smiles and says, "I know."

Koons tells me Cammer's kind attention and enthusiasm for nursing has helped make the hospital stay more comfortable.

"They've been really nice, very efficient, gave me plenty of blankets because it's really cold in this place," Koons says. Koons and her stepfather, Raymond Zwack, agree they'd give Medical Park a perfect 10 on the satisfaction scale.

My poll of the family is informal, but Medicare has been taking actual surveys of patient satisfaction, and hospitals are paying strict attention. The Affordable Care Act ties a portion of the payments Medicare makes to hospitals to how patients rate the facilities.

Medical Park, for example, recently received a $22,000 bonus from Medicare in part because of its sterling results on patient satisfaction surveys.

Medical Park Hospital's patients tend to be pretty happy customers, leading to thousands of dollars in rewards from Medicare.

Novant Health

Novant Health is Medical Park's parent company, and none of its dozen or so other hospitals even come close to rating that high on patient satisfaction. Figuring out why Medical Park does so well is complicated.

First, says Scott Berger, a staff surgeon, this isn't your typical hospital.

"It kind of feels almost like a mom-and-pop shop," he says.

Medical Park is really small, only two floors. Doctors just do surgeries, like fixing shoulders and removing prostates, and most of their patients have insurance.

Another key is that no one at Medical Park was rushed to the hospital in an ambulance or waited a long time in the emergency room. In fact, the hospital doesn't even have an emergency room.

The hospital doesn't tend to do emergency surgeries, says Chief Operating Officer Chad Setliff. These procedures are all elective, scheduled in advance. "So they're choosing to come here," he says. "They're choosing their physician."

These are the built-in advantages that small, specialty hospitals have in terms of patient satisfaction, says Chas Roades, chief research officer with Advisory Board Company, a global health care consulting firm.

"A lot of these metrics that the hospitals are measured on, the game is sort of rigged against [large hospitals]," Roades says.

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This is the third year hospitals can get bonuses or pay cuts from Medicare — partly determined by those scores — that can add up to hundreds of thousands of dollars.

More typical hospitals that handle many more patients — often massive, noisy, hectic places — are more likely to get penalized, Roades says.

"In particular, the big teaching hospitals, urban trauma centers — those kind of facilities don't tend to do as well in patient satisfaction," he says. Not only are they busy and crowded, but they also have many more caregivers interacting with each patient.

Still, Roades says, although patient surveys aren't perfect, they are fair.

"In any other part of the economy," he points out, "if you and I were getting bad service somewhere — if we weren't happy with our auto mechanic or we weren't happy with where we went to get our haircut — we'd go somewhere else." In health care, though, patients rarely have that choice. So Roades thinks the evaluation of any hospital's quality should include a measurement of what patients think.

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Medical Park executives say there are ways big hospitals can seem smaller — and raise their scores. Sometimes it starts with communication— long before the patient shows up for treatment.

On my recent visit, Gennie Tedde, a nurse at Medical Park, is giving Jeremy Silkstone an idea of what to expect after his scheduled surgery — which is still a week or two away. The hospital sees these conversations as a chance to connect with patients, allay fears and prepare them for what can be a painful process.

"It's very important that you have realistic expectations about pain after surgery," Tedde explains to Silkstone. "It's realistic to expect some versus none."

Medical Park now handles this part of surgery prep for some of the bigger hospitals in its network. Silkstone, for example, will have surgery at the huge hospital right across the street — Forsyth Medical Center.

Carol Smith, the director of Medical Park's nursing staff, says that after she and her colleagues took over these pre-surgical briefings, "Forsyth's outpatient surgical scores increased by 10 percent."

But some doctors and patients who have been to both hospitals agree that the smaller one is destined to have higher scores. It is just warmer and fuzzier, one patient says.

This story is part of NPR's reporting partnership WFAE and Kaiser Health News.

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Beyond BPA: Court Battle Reveals A Shift In Debate Over Plastic Safety

NPR Health Blog - Mon, 02/16/2015 - 3:42am
Beyond BPA: Court Battle Reveals A Shift In Debate Over Plastic Safety February 16, 2015 3:42 AM ET Listen to the Story 4 min 57 sec  

Eastman Chemical went a step beyond calling Tritan plastic BPA-free, setting off a legal challenge.


BPA-free isn't good enough anymore if you're trying to sell plastic sippy cups, water bottles and food containers.

The new standard may be "EA-free," which means free of not only BPA, short for bisphenol A, but also free of other chemicals that mimic the hormone estrogen.

At least that's the suggestion of a recent legal battle between a chemical company and an academic scientist with business interests in the plastics industry. The proceedings offer a glimpse of the struggle for the hearts and minds of consumers concerned about the safety of plastics.

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The roots of the legal conflict go back to 2002, when Eastman Chemical began developing a new plastic called Tritan. It was designed to be "a tough, clear, high-temperature, chemically resistant and also dishwasher-resistant product," says Chris Killian, a vice president for specialty products at Eastman.

Tritan had another desirable quality: Unlike many plastics, it didn't contain BPA, a chemical that, in large doses, caused hormone-related health problems in animals.

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The absence of BPA in Tritan was a fortunate accident, Killian says, one that gave the new plastic a big boost when Eastman began selling it in 2007.

By then, many consumers were avoiding products made with BPA. And the FDA was still trying to decide whether these products posed any health risk. The uncertainty surrounding BPA gave Tritan a big boost, Killian says.

"We certainly became aware of the growing interest from both the consumers and from some of our customers with respect to having a BPA-free alternative," he says. "But none of us could have predicted the magnitude of that interest."

Tritan became a hit. And that's when a scientist and businessman named George Bittner entered the picture.

Bittner is a professor of neuroscience at the University of Texas at Austin. Long before Tritan came along, he had concluded that BPA wasn't the only chemical in plastics that could act like estrogen.

"There are a couple of hundred or maybe a couple thousand other chemicals that are used to make some kinds of plastics that are almost certainly as much a problem as BPA," Bittner says.

Bittner believed this so strongly that he founded PlastiPure, a company involved in making plastics without estrogenic chemicals, and CertiChem, a company that tests plastics for what's known as estrogenic activity. Over the years, Bittner would put millions of dollars into these ventures.

As he worked to get his companies going, Bittner — and some other scientists — began preaching the gospel that consumers shouldn't settle for products that were merely free of BPA. They should demand products that were free of any chemical with estrogenic activity.

By the time Tritan arrived in 2007, people were starting to listen. "This trend, if you will, or this consumer preference began to evolve and grow in the same way BPA did," Killian says.

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In response, Eastman added "EA-free" to Tritan's resume. There was just one problem. PlastiPure had begun distributing marketing materials saying that Tritan products were not free of estrogenic activity under certain conditions.

So, in 2012, Eastman sued PlastiPure. Each side trotted out experts and studies backing its position. They argued at length about which tests should be used to establish whether a product had estrogenic activity.

In 2013, a federal jury sided with Eastman and the court told PlastiPure and CertiChem to change their marketing tactics. In December 2014, an appeals court upheld that ruling.

As a result, Bittner's companies have changed their tactics a bit, says Mike Usey, the CEO of PlastiPure. "We don't talk about Tritan, or Eastman, in a commercial context concerning the testing results that we have," he says. "But that doesn't limit our discussing our research in a scientific context."

That means Bittner and his companies are getting their message out by publishing scientific papers about estrogenic plastics that specifically mention Tritan and products made with it.

The tactic seems to be effective, Bittner says. "I think people are recognizing that it's not the courts that determine scientific questions," he says.

So the struggle for consumers' hearts, minds and wallets goes on. Eastman reports that sales of Tritan continue to grow. PlastiPure has announced plans for a new line of baby bottles that meet its own definition of EA-free.

Meanwhile, the FDA has reached a conclusion about BPA, the chemical that first got consumers worried about plastics that could act like hormones. Late in 2014, the agency issued a statement reiterating its position that products made with BPA are safe.

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When A Patient Says 'Everything's Fine,' A Doctor Should Be Wary

NPR Health Blog - Sun, 02/15/2015 - 5:45am
When A Patient Says 'Everything's Fine,' A Doctor Should Be Wary February 15, 2015 5:45 AM ET


Lucinda Schreiber for NPR

Oscar buzz surrounds Julianne Moore for her role as Alice Howland in the film Still Alice. Howland is a linguistics professor who develops early-onset Alzheimer's, a cruel irony for a character who makes her living with her brain.

Howland's awareness of her fate makes her decline all the more painful to watch.

Often, though, patients and their doctors can be slow to recognize dementia, which most often progresses gradually.

Patients can be all over the spectrum with regard to age-related decline in memory. At what point does mild cognitive impairment progress to outright dementia?

Like a retired cop who was 73 when he came under my care. He had high blood pressure, Type 2 diabetes and high cholesterol. All were under control with the help of medicines he was good about taking.

Here's how our typical visit would go.

"Any problems today?" I would ask.

"Nope," he would answer. "Everything's fine."

During our first visit he told me that he was an early morning mall-walker, part of an exercise group. To me, this was a good sign physically and socially.

I asked how his wife was. "She made me promise to give this to you," he said.

He unfolded a piece of lined memo paper with neat cursive handwriting. On it was a list of his medications and their doses; the ones that needed refilling were starred. There was also a question about pain in his right knee, and a suggestion to check his hemoglobin A1c, a test used to monitor blood sugar control for people with diabetes.

This all seemed reasonable enough. But I wondered why if he had knee pain, he needed a note from his wife to tell me about it.

"What's going on with your knee?" I asked.

"Not much. I guess sometimes it's a little stiff," he offered.

I liked the man. He was affable and pretty typical of my older male patients: stoic about all things medical, and unlikely to complain in response to an open-ended question. They tend to live by the motto, if it ain't broke, don't fix it.

I made a mental note about him: not forthcoming with medical complaints.

In his chart, I documented that he'd brought a note from his wife and what the issues were that she'd hoped I would address. The comment about his wife's note was to jog my memory about this dynamic at any subsequent appointment.

At this point, you might be thinking, "What kind of guy needs a note from his wife to remind his doctor about knee pain?" I know I did.

I saw him several times over the next few years. Each visit followed the same pattern. I'd ask him how he was. He'd always answer, "Just fine." He always had a note from his wife that would itemize his medicines necessary refills, and usually include a question or two about testing for his chronic conditions.

I looked forward to having him on my schedule. He was an easy patient, never taking more than his allotted 15 minutes. Each time he'd come, we'd have a quick, pleasant chat and then "take care of business" following the outline from his wife.

His visits were a model of efficiency.

And that was a problem. A doctor has a sixth sense, or should, that when things are going too smoothly there's probably more to the story.

Four years after I first met him, he began bleeding from his gastrointestinal tract. He was hospitalized twice. We couldn't find the cause of his bleeding. But the health crises sent him into a profound delirium that left him unable to identify where he was or recognize his wife and other relatives while in the hospital.

Geriatricians have long realized that there's a strong correlation between an episode of delirium like this and underlying dementia. Even in patients without dementia, becoming delirious in the hospital often leads to persistent cognitive impairment (errors in memory, speech, judgment, or calculation) that lasts up to a year.

After his third hospitalization for bleeding, my patient had surgery to remove the part of his colon that seemed to be the cause. This time, with the added fog of anesthesia, he deteriorated so badly that he wound up in the intensive care unit for days.

It was a harrowing time for his wife and their children.

Fortunately, my patient weathered the ICU and survived his operation. After a several weeks at rehab, he returned home and resumed mall-walking, household chores and even driving.

Some things changed. After that, his wife came with him to his office visits. Her lists of questions also grew longer.

And then during one routine visit, she remarked, "You know, he's been given a diagnosis of Alzheimer's."

This news didn't totally surprise me. She'd decided to have him evaluated by a neurologist because of his persistent problems.

Still, her comment made me feel guilty. I wasn't certain why, so after the visit I reflected on it.

It occurred to me that his wife's comment made me feel like she was criticizing me for missing her husband's Alzheimer's.

The truth is, I hadn't wanted to look. The red flags had been there: stereotypical visits with nary a complaint, little regard for current events and limited memory of our previous encounters.

In retrospect, I realize that my patient was adroit at masking his dementia. He was still capable of small talk. Since I didn't probe very hard, I wasn't going to find out the degree of memory loss that he'd already suffered.

Of course, his wife's notes should have been the biggest clue.

Labeling patients with Alzheimer's can be devastating. It's telling them that they have an incurable, progressive illness that won't only destroy their mind but in all likelihood ravage the lives of their caregivers as well.

I hadn't wanted to inflict this diagnosis on my patient and his family.

I was wrong. In hindsight, the diagnosis would have benefited them in at least two ways.

Most directly, knowing that the man had some degree of dementia would have helped us all anticipate that he was at risk for big trouble in the hospital.

Secondly, an earlier diagnosis of Alzheimer's would have given his wife more time and knowledge to care for her husband and plan for the future.

Even when we doctors can't cure a patient, we should aim to provide families with the right resources and information to help them. Too often I think doctors fail to do this because we're so focused on what's happening at the moment during our in-person visits.

After my experience with this patient, I'm trying harder to look beyond what's right in front of me and examine each patient's living situation and capabilities. Though it's tempting and easier, I no longer settle for "everything's fine."

John Henning Schumann is a writer and doctor in Tulsa, Okla. He was recently named Interim President of the University of Oklahoma - Tulsa. He also hosts Public Radio Tulsa's Medical Matters. He's on Twitter: @GlassHospital

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California Health Exchange Considers Extending Enrollment For Some

NPR Health Blog - Fri, 02/13/2015 - 8:07am
California Health Exchange Considers Extending Enrollment For Some February 13, 2015 8:07 AM ET


Lisa Aliferis

Covered California may extend the enrollment deadline for health coverage far beyond Feb. 15.


Covered California open enrollment ends this Sunday. Sort of.

For starters, the agency announced Thursday that people who start an application by this Sunday get until next Friday, Feb. 20, to finish it. That's similar to steps that Covered California has taken in the past.

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But advocates have long been frustrated with the timing of open enrollment. That's because of how penalties for lacking insurance are assessed — on your taxes. The tax deadline isn't for another two months, April 15.

It's easy to imagine that plenty of people will discover the penalty as they file their taxes over the next two months — and simultaneously discover they could be locked out of buying insurance.

In a surprise, Peter Lee told me Thursday afternoon that Covered California, the state's health insurance exchange, is considering "contingency plans."

He said the exchange will be "looking actively" at people who might not have understood there was a penalty. "Do we make a special provision for them between now and the end of tax season?" he said.

Lee stressed there has been no decision and that Covered California is focusing now on getting through open enrollment. "But this is a major issue and we're going to be looking at this in the next week or two," he said.

Lee said the move wouldn't require action by exchange's board. "Covered California has the authority to adopt special enrollment criteria if consumers didn't have the opportunity and didn't have the information to enroll," Lee said.

Anthony Wright, executive director of Health Access, an advocacy group, seemed intrigued by the idea. "We were never big fans of the open enrollment period to begin with," he said.

Wright said that an additional enrollment period "would attract generally healthy people into coverage," arguing that people who are sick are likely already in the system.

Wright said there was no federally mandated open enrollment period. His agency had advocated at the federal level to tie the open enrollment more closely to the tax season. The current open enrollment started Nov. 15 and runs through Sunday. "You lose a lot of time during the holidays," Wright said, "because no one is focused on (health insurance)."

Nicole Evans, spokeswoman for the California Association of Health Plans, said, "This is the first we've heard of it," and declined to comment as the organization had not received any "official communication" from Covered California.

Last year's open enrollment ran more than six months, Wright pointed out. The open enrollment period "is not handed down in stone," he said. "We can take a look at it."

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